779 RIVERSIDE RECOVERY & COUNSELING SERVICES — NPI 1437636131 (Licensed & Credentialed Counselor, Addiction (Substance Use Disorder) in EDINA, MN)

CMS-1500 Box 24J / 33a • NPI

1437636131

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

101YA0400X

Licensed & Credentialed Counselor, Addiction (Substance Use Disorder)

Box 32 Service Location & ZIP+4

4940 W 77TH ST, EDINA, MN, 55435-4805

✓ 9-Digit EDI 837 ZIP+4 (55435-4805)

Practice Phone & Referral Fax

(612) 223-6622

Direct NPPES Verification Line

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1437636131 (779 RIVERSIDE RECOVERY & COUNSELING SERVICES) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1437636131` (NPI-2 Organization / Facility)
Provider / Legal Name	779 RIVERSIDE RECOVERY & COUNSELING SERVICES
Plain-English Specialty	Licensed & Credentialed Counselor, Addiction (Substance Use Disorder) NUCC Code: `101YA0400X` (Counselor, Addiction (Substance Use Disorder))
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	4940 W 77TH ST, EDINA, MN, 55435-4805
Practice Telephone / Fax	Tel: (612) 223-6622
Administrative Mailing Address	8014 HIGHWAY 55 UNIT 197, GOLDEN VALLEY, MN, 55427-4712
Enumeration & Last Sync	Enumerated: 2018-07-25 \| CMS Record Updated: 2018-07-25
Authorized Official	COACH NAKUMBE (Owner / Clinical Director)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

4940 W 77TH ST, EDINA, MN, 55435-4805

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Plain-English Taxonomy & CMS Crosswalk (101YA0400X)

What Does Taxonomy Code 101YA0400X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 101YA0400X translates to:
"Licensed & Credentialed Counselor, Addiction (Substance Use Disorder)"

CMS-1500 Medicare Specialty Crosswalk: Standard HIPAA X12N 837P / CMS-1500
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Counselor, Addiction (Substance Use Disorder) for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (779 RIVERSIDE RECOVERY & COUNSELING SERVICES)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`101Y00000X` — Counselor Plain English: Licensed & Credentialed Counselor	State: MN \| License: `00935` \| Primary: Secondary
`101YM0800X` — Counselor, Mental Health Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Counselor	State: MN \| License: `00935` \| Primary: Secondary
`101YP2500X` — Counselor, Professional Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Counselor	State: MN \| License: `00935` \| Primary: Secondary
`103TB0200X` — Psychologist, Cognitive & Behavioral Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Psychologist, Cognitive & Behavioral	State: MN \| License: `00935` \| Primary: Secondary
`103TC0700X` — Psychologist, Clinical Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Psychologist, Clinical	State: MN \| License: `00935` \| Primary: Secondary
`103TP2701X` — Psychologist, Group Psychotherapy Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Psychologist, Group Psychotherapy	State: MN \| License: `00935` \| Primary: Secondary
`261QM0850X` — Clinic/Center, Adult Mental Health Plain English: Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center	State: MN \| License: `00935` \| Primary: Secondary
`261QM0855X` — Clinic/Center, Adolescent and Children Mental Health Plain English: Licensed Outpatient Medical Clinic / Urgent Care & Ambulatory Center	State: MN \| License: `00935` \| Primary: Secondary
`101YA0400X` — Counselor, Addiction (Substance Use Disorder) Plain English: Licensed & Credentialed Counselor, Addiction (Substance Use Disorder)	State: MN \| License: `303344` \| Primary: Yes (Primary)

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779 RIVERSIDE RECOVERY & COUNSELING SERVICES (NPI #1437636131)